The Facts

Post-traumatic stress disorder, or PTSD, is a new name for a very old condition. In the earlier 1900s, it was known as "shell shock" or "battle fatigue." Before then, it had no name. In PTSD, a witness or victim of a terrible event or tragedy is so haunted by memories of the event that personal health and personality is affected. These symptoms persist for more than one month after the traumatic event, and occur together with other conditions such as depression, anxiety, or substance abuse.

Research suggests that 9.2% of the Canadian population will be affected at one time in their life with PTSD. Women are twice as likely to be affected as men. The specific type of trauma is important in the gender distribution. For example, women exposed to a physical attack or threatened with a weapon are more likely to develop PTSD than men who are exposed to the same trauma. But women who are sexually assaulted are less likely to develop PTSD than men who are sexually assaulted. About 76% of Canadians have been exposed to at least one traumatic event in their lifetime and about 43% of those individuals can present with PTSD.

Causes

The kinds of events that can trigger PTSD were traditionally limited to the most violent and frightening situations, such as being involved in a plane crash, a shooting, or the collapse of a building after an earthquake or bomb. The main source of such trauma is war, and in North America the largest category of PTSD sufferers are war veterans. Much of what we know about this syndrome comes from studies involving former soldiers.

More recently, the definition has broadened. People who suffer rape or physical or sexual abuse may react in much the same way as those who have witnessed carnage or been threatened by violent death. Particular risk factors such as early age trauma, a history of childhood abuse, personality or psychiatric disorders, or a family history of psychosis, may make certain individuals more likely to have post-traumatic stress disorder. In this context, PTSD among children has become a major focus because they are particularly likely to develop the symptoms associated with this condition.

In Canada, the lifetime rate of PTSD was highest in those who were sexually assaulted or had experienced a sudden, unexpected death of a loved one.

Symptoms and Complications

The most noticeable signs in a person suffering from PTSD are introversion and joylessness. People with this syndrome are unable to take pleasure from things they might have enjoyed in the past. They avoid the company of others and become generally more passive than before. They wish to avoid anything that will trigger memories of the traumatic event. A person with PTSD might drift out of a conversation and appear distant and withdrawn. This is known among soldiers as a "thousand-yard stare." This is a sign that unpleasant memories have returned to haunt them.

Having trouble sleeping is almost inevitable in this syndrome. Nightmares are common, and even when someone with PTSD is not thinking about the event, sleep is often disturbed. A common symptom among veterans is nocturnal myoclonus, a sudden spasm of the whole body while sleeping or drifting off into sleep. It lasts for about a fraction of a second, but may occur several times in a single night. Often people with PTSD will sleep through such a spasm, but their partner may not. Children with PTSD may have many nightmares, yet those dreams may not contain anything that's obviously related to the original trauma.

Psychiatrists speak of three symptoms that define PTSD – intrusion, avoidance, and hyperarousal.Intrusion is the inability to keep memories of the event from returning. Avoidance is an attempt to avoid stimuli and triggers that may bring back those memories. Hyperarousal is similar to jumpiness. It may include insomnia (trouble sleeping), a tendency to be easily startled, a constant feeling that danger or disaster is nearby, an inability to concentrate, extreme irritability, or even violent behaviour.

Depression is very likely to go hand in hand with PTSD, and in severe cases, suicide is a real danger. People with this syndrome, as with any psychiatric illness, are more likely than average to abuse alcohol or drugs. Psychiatrists see this as an attempt to self-medicate the condition, but naturally the drugs involved are very unlikely to improve the situation. People with PTSD are 2 to 4 times more likely to suffer from depression, anxiety, or substance abuse.

Making the Diagnosis

The diagnosis of PTSD is based on 5 specific features that must be present for at least one month and cause significant distress or impact on a person's daily life and functioning that is not caused by another medical condition, medication, or substance (e.g., alcohol):

exposure to a traumatic event

re-experiencing symptoms after the trauma – intrusive thoughts or recollections, recurrent dreams of the trauma, flashbacks of the trauma

avoidance symptoms – avoiding thinking about the trauma, avoiding people or places that remind you of the trauma

“numbing” symptoms – inability to remember specifics about the trauma, detachment, diminished interest in activities, detachment from others, inability to experience positive kinds of emotions, negative feelings about oneself or the world

A diagnosis of PTSD may also present with particular subtypes. Some people may have dissociative symptoms in which they persistently feel detached from their mental state (depersonalization) or feel that they are out-of-sync with reality, as if they are in a “dream-like” state (derealization). Others may have a delayed expression, meaning that they don’t quite meet the requirements for PTSD until at least six months after the traumatic event.

Treatment and Prevention

Treatment can be effective for PTSD and involves psychological intervention as well as medications.

The main psychological treatment for treating PTSD is cognitive-behavioural therapy. This means examining the thought processes associated with the trauma, the way memories return, and how people react to them. PTSD often fades over time, even without treatment, and the goal of therapy is to accelerate that natural healing process.

Because the horror may fade over time, being confronted with memories of the trauma when in a safe situation may help a person over time to become less frightened or depressed by those memories. This is called desensitization, which is often combined with cognitive behavioural therapy. Psychological treatments are particularly helpful for the "re-experiencing symptoms" and any social or vocational impairment caused by PTSD.

Medications that may be used in treatment are serotonin reuptake inhibitor (SSRIs). Most people with PTSD will benefit from taking antidepressant medications, whether or not they have clinical depression accompanying their PTSD. They help with decreasing negative symptoms, such as irritability, anger, or depression, but have little effect on the avoidance and numbing symptoms of PTSD. SSRIs are usually started at low doses and increased slowly. It normally takes 4 to 6 weeks to determine the full effectiveness of the medication. Drowsiness and sexual dysfunction are common side effects of these medications. Less commonly, medications called serotonin-norepinephrine reuptake inhibitors (SNRIs) may be used to treat PTSD.

Other medications (e.g., those that help balance mood and reduce mood swings, or antipyschotics) may also help to relieve symptoms.